Analysis Generator Fuel Usage In order to load maximum cargo in Great Lakes ports, ocean-going vessels often forego bunkering until they reach deep-water ports such as Montreal. The HopeI loaded cargo to maximum Seaway draught in Thunder Bay with the intention of topping off cargo at Port Cartier. As a result, the vessel had only a modest amount of diesel oil on board when she departed Thunder Bay, and could only take 10tonnes when she stopped for fuel in Port Colborne two days before the occurrence. Records indicate a total of 32tonnes of diesel oil on board following bunkering. Two days before the blackout, at 0900 on June 1, the generator service tank contained 10tonnes of diesel fuel. It is reported that between then and the time of the blackout, no fuel was transferred to this tank. Given an average fuel consumption of two tonnes a day for each generator, approximately eight tonnes would have been used between 0900 on June1 and 0900 on June3, leaving little usable fuel in the tank just prior to the occurrence. While supplying fuel to the generators after the blackout, diesel oil was allowed to flow by gravity from the main engine diesel oil service tank to the generator service tank. When the level in the generator service tank rose to the float level, the low level alarm light went out. This fact and subsequent tests conducted by the TSB indicate that the low level alarm for the generator diesel oil service tank was functioning properly at the time of the occurrence. The engine-room staff was not aware that the internal arrangement of the generator service tank was such that the fuel below the suction pipe was unusable, the tank sounding tables did not indicate that this was the case, and reliance was placed on soundings which showed that there were about two and a quarter tonnes of fuel remaining in the tank. These factors combined to influence the engineer's decision to ignore the low level alarm. However, the combination of the known average fuel consumption and the low level alarm, reinforced by the 1000 sounding, should have provided ample warning that the level of fuel in the generator service tank was critically low. ISM Code Application The application of the ISM Code to bulk carriers such as the HopeI resulted from a growing number of marine occurrences that were clearly due to a lack of good management systems and shipboard practices. In applying the ISM Code, shipping companies minimize the range of poor human performance-based decisions that may lead to an accident. The provision of adequate policies and procedures enables the ship's crew to be better equipped to make correct decisions of a day-to-day operational nature. Fuel handling is one of the most critical operational routines on board any vessel. Twelve hours before the blackout on board the HopeI, the generator service tank low level alarm gave an indication that the level in the tank had dropped to a minimum acceptable level.3 Notwithstanding the altered log book entries, the chief engineer and the engine-room watch-keepers were aware that the alarm was on and that the tank level might be low; however, no shipboard safety management procedures were in place to ensure that an adequate level of fuel was maintained or that fuel was transferred to the tank. As a result, even though the alarm continued to give an indication of low fuel level up to the time of the occurrence, no decision was made to transfer fuel, resulting in fuel starvation to the generators and loss of power to the vessel. Such actions were not consistent with the engine-room procedures contained in the vessel's safety management system. These procedures were general in nature and not specific to the HopeI; as a result, they did not help to ensure that conditions and activities on board that affected safety were planned, executed and checked. Emergency Power to Steering Systems Navigating in confined waters demands special vigilance by staff and the security derived from redundant systems on board; however, many vessels transiting confined waters in Canada are not designed or equipped with emergency power supplies to their steering systems. Prior to 1984, international regulations did not require that emergency power be available to steering systems.4 As a result, vessels (otherthantankers) which were built before this time are grand-fathered from the more stringent current steering gear regulations. In a previous occurrence investigated by the TSB, the Liberian-registered bulk carrier ChristofferOldendorfexperienced a blackout and subsequently grounded in Lake Saint-Pierre, Quebec.5 The investigation revealed that the vessel was not equipped with an emergency power supply to the steering gear. At the time of the blackout on the HopeI, the emergency generator started immediately and supplied power to the emergency lighting throughout the vessel. However, the emergency power system was not designed to supply power to the steering gear, nor was it required to be. With the rudder to port and no emergency power available to restore steering control, the vessel continued to swing to port and grounded outside the channel. The vessel was transiting the Seaway with a modest supply of diesel oil on board. The low level alarm for the generator service tank activated 12hours prior to the occurrence. There was no appropriate means of determining the amount of diesel oil in the generator service tank from inside the engine-room. The engine-room staff were not aware that the internal arrangement of the generator service tank was such that the last 1.8tonnes were unpumpable. The engine-room staff did not transfer diesel oil to the tank. No formal procedures were in place regarding fuel transfer operations. Generators No1 and No3 stopped due to fuel starvation. The emergency generator started immediately after the blackout. The emergency switchboard was not designed to be connected to the steering gear, nor was it required to be. With no steering control, the vessel sheered to port and grounded near Morrisburg, sustaining hull damage.Findings The vessel was transiting the Seaway with a modest supply of diesel oil on board. The low level alarm for the generator service tank activated 12hours prior to the occurrence. There was no appropriate means of determining the amount of diesel oil in the generator service tank from inside the engine-room. The engine-room staff were not aware that the internal arrangement of the generator service tank was such that the last 1.8tonnes were unpumpable. The engine-room staff did not transfer diesel oil to the tank. No formal procedures were in place regarding fuel transfer operations. Generators No1 and No3 stopped due to fuel starvation. The emergency generator started immediately after the blackout. The emergency switchboard was not designed to be connected to the steering gear, nor was it required to be. With no steering control, the vessel sheered to port and grounded near Morrisburg, sustaining hull damage. The HopeI grounded as a result of a blackout due to fuel starvation of the generators. Contributing to the occurrence were the inadequate means of determining the amount of fuel in the generator service tank from inside the engine-room, the inadequate fuel transfer procedures, the fact that the engine-room staff did not transfer fuel to the generator service tank and were unaware of the amount of unpumpable fuel in the tank, and the lack of an emergency power supply to the steering gear.Causes and Contributing Factors The HopeI grounded as a result of a blackout due to fuel starvation of the generators. Contributing to the occurrence were the inadequate means of determining the amount of fuel in the generator service tank from inside the engine-room, the inadequate fuel transfer procedures, the fact that the engine-room staff did not transfer fuel to the generator service tank and were unaware of the amount of unpumpable fuel in the tank, and the lack of an emergency power supply to the steering gear. Subsequent to the occurrence, a low fuel level notation was added to the Alternator Service Tank sounding tables on board the vessel.Safety Action Subsequent to the occurrence, a low fuel level notation was added to the Alternator Service Tank sounding tables on board the vessel.